IMAGES IN EMERGENCY MEDICINE
Warren Johnson, MD
Nirav Shastri, MD
Milton Fowler, MD
University of Missouri–Kansas City, Children’s Mercy Hospitals and Clinics, Division of
Emergency and Urgent Care, Kansas City, Missouri
Supervising Section Editor: Sean Henderson, MD
Submission history: Submitted March 15, 2011; Revision received March 16, 2011; Accepted March 21, 2011
Reprints available through open access at http://escholarship.org/uc/uciem_westjem
[West J Emerg Med. 2011;12(4):370.]
A 4-year-old boy underwent a tonsillectomy and
adenoidectomy for tonsillar and adenoidal hypertrophy. The
patient developed difficulty breathing after a nonbloody emesis
during the car ride home after surgery. The parents noticed a
mass in the patient’s mouth and brought him to the clinic. On
examination, he had normal vital signs with no respiratory
distress and a pulse oximetry of 98% in room air. His
oropharynx revealed a markedly edematous, nonerythematous
uvula, which was deviated anteriorly and resting on the tongue
(see Figure). The tonsillar beds were not bleeding. The rest of
his examination yielded normal results.
Isolated angioedema of the uvula is termed Quincke’s
disease.1Causes include trauma, inhalation exposure, for
example, marijuana, general anesthesia, medication reaction
(angiotensin converter enzyme inhibitors), infections, and
Most reports of uvular edema after ear, nose, and throat
procedures are caused by trauma.2Trauma occurs from the
laryngoscope blade during intubation, owing to an
oropharyngeal airway, overzealous suctioning, twisting of the
uvula during endotracheal tube placement, entrapment of the
uvula between the nasal airway and the endotracheal tube, or
owing to pressure from a nasogastric tube.
The immediate treatment of uvular edema depends on the
degree of airway compromise. Intravenous line should be
established and intubation equipment set up at the bedside.
Medications used to reduce swelling include epinephrine,
diphenhydramine, cimetidine, and methylprednisolone. Patients
with suspected noninfectious cause, who do not respond to the
above medications, may have a complement deficiency and
should also receive plasminogen inhibitor e-aminocaproic
Our patient received intravenous methylprednisolone,
diphenhydramine, and intramuscular epinephrine. He was
admitted overnight for observation and discharged home the
next day as his symptoms improved significantly. Our patient
was not tested for any underlying hereditary cause.
Address for Correspondence: Warren Johnson, MD, University of
Missouri–Kansas City, Children’s Mercy Hospitals and Clinics,
Division of Emergency and Urgent Care, 2401 Gillham Rd, Kansas
City, MO 64108. E-mail: firstname.lastname@example.org.
Conflicts of Interest: By the WestJEM article submission
agreement, all authors are required to disclose all affiliations,
funding sources, and financial or management relationships that
could be perceived as potential sources of bias. The authors
1. Deutsch ES, Zalzal GH. Quincke’s edema, revisited. Arch Otolaryngol
Head Neck Surg. 1991;117:100–102.
2. Diaz JH. Is uvular edema a complication of endotracheal intubation?
Anesth Analg. 1993;76:1139–1141.
3. Goldber R, Lawton R, Newton E, Line WS Jr. Evaluation and
management of acute uvular edema. Ann Emerg Med. 1993;22:251–255.
4. Haselby KA, McNiece WL. Respiratory obstruction from uvular edema in
a pediatric patient. Anesth Analg. 1983;62:1127–1128.
Figure. Swollen edematous uvula.
Western Journal of Emergency MedicineVolume XII, NO. 4 : November 2011370